Percutaneous transhepatic duodenal drainage is good option for afferent loop syndrome for obstructive colorectal cancer patient with history of Billroth's operation II: A case report of a rare postoperative complication

Key Clinical Message Temporal percutaneous transhepatic duodenum drainage (PTDD) seems to be effective in the treatment of postoperative afferent loop syndrome (ALS) following transverse loop colostomy for obstructive colorectal cancer. Abstract Management of obstructive colorectal cancer still remains a challenge. There are various options with different risks of mortality and mobility for obstructive colorectal cancer. A rare unexpected postoperative ALS following a low anterior resection and transverse loop colostomy for obstructive colorectal cancer is presented in this report. A 64‐year‐old man had the acute ALS had been noted 10 days after transverse loop colostomy. An option was temporal PTDD treatment in the patient with history of Billroth's operation II for upper gastrointestinal bleeding 30 years ago. Acute ALS was treated by temporal PTDD. The drainage tube for PTDD was not removed until closure of the transverse colostomy 2 months later. The patient recovered uneventfully. Acute ALS after transverse loop colostomy for obstructive colorectal cancer is rare and has never been reported in the literature. The mechanism of acute ALS after construction of a loop colostomy and the treatment strategy of PTDD for acute ALS is presented.

are various options with different risks of mortality and mobility for obstructive colorectal cancer. A rare unexpected postoperative ALS following a low anterior resection and transverse loop colostomy for obstructive colorectal cancer is presented in this report. A 64-year-old man had the acute ALS had been noted 10 days after transverse loop colostomy. An option was temporal PTDD treatment in the patient with history of Billroth's operation II for upper gastrointestinal bleeding 30 years ago. Acute ALS was treated by temporal PTDD. The drainage tube for PTDD was not removed until closure of the transverse colostomy 2 months later.
The patient recovered uneventfully. Acute ALS after transverse loop colostomy for obstructive colorectal cancer is rare and has never been reported in the literature. The mechanism of acute ALS after construction of a loop colostomy and the treatment strategy of PTDD for acute ALS is presented.

| INTRODUCTION
Obstructive rectal cancer is an emergency condition. The management still remains a challenge. The risks of ischemia bowel and perforation of colon may occur if the operation was delayed. There are various options with different risks of mortality and mobility for obstructive rectal cancer, such as stenting, one stage resection anastomosis, total colectomy, resection of obstructive rectal cancer plus a prophylactic loop colostomy, Hartmann's operation or simple colostomy. 1,2 Afferent loop syndrome (ALS) is usually developed as a complication after gastrectomy with gastrojejunostomy. 3 But the acute ALS was found 10 days after T-loop colostomy on our patient who experienced the B-II operation 30 years ago. It was caused by traction of transverse loop colostomy and treated with temporal percutaneous transhepatic duodenum drainage (PTDD). The non-surgical palliative PTDD is good option for acute afferent syndrome in status of T-loop colostomy.

| CASE PRESENTATION
A 64-year-old man was sent to our emergency room due to abdominal pain, fullness of abdomen and no stool passage for 4 days. He had history of peptic ulcer with bleeding post B-II operation 30 years ago. The heart rate 94 beats/ min, blood pressure 147/100 mmHg, and respiratory rate 20 breaths/min were found. Abdomen was tenderness without rebounding pain and ovoid in shape. An old surgical scar located upper mid-line of abdomen. Metallic sound was noted. Kidney-ureter-bladder abdominal radiography (KUB) and computed tomography (CT) of abdomen demonstrated intestinal obstruction with mass lesion over rectum-sigmoid junction ( Figure 1). Fiberoptic colonoscopy revealed an ulcerative solid mass around 4 cm in diameter causing totally obstruction which was 15 cm proximal to anus. Low anterior resection, on-table lavage, anastomosis with EEA 29 (Ethicon; Johnson & Johnson), and prophylactic transverse loop colostomy had been performed right after colonoscopy. Antecolic anastomosis of previous gastrojejunostomy was noted while did the transverse loop colostomy. The colostomy was constructed 5 cm left to the umbilicus. Hiccup and fullness of abdomen were suffered at the 3rd day after surgery. Two shallow, active ulcers at LCS of remnant stomach were found near the anastomosis of gastrojejunostomy in panendoscopy at the 5th operation day. Afferent and efferent loops were noted as well. Liquid diet with 500-1000 mL/day was given in spite of persisting hiccup. Tachycardia with rate of 100-120 beats/min and abdominal pain over right upper quadrant (RUQ) region happened at the 9th operation day. Abrupt fever (temperature, 38.5°C) followed at the 11th day. The laboratory tests showed WBC was 12,100/mm3, amylase 214 U/L, and total bilirubin 5.1 mg/ dL. Abdominal CT scan revealed afferent loop obstruction at the level of Treitz ligament with mild biliary tract dilation ( Figure 2). The PTDD was performed right after percutaneous cholangial drainage (PTCD) (Figure 3).

| DISCUSSION
The cause of afferent loop obstruction can be benign or malignant lesions. Acute ALS usually accompanies with abrupt epigastric pain, non-bilious vomiting in early phase of recovery. Chronic ALS usually occurs months or years after surgery, accompanying with partial obstruction and subsides with bilious vomiting 1-2 h after meal. 3 ALS after transverse loop colostomy for obstructive colorectal cancer is extremely rare. According to PubMed search engine, we found the literature of obstructive colorectal cancer with ALS has never been reported and identified. A few cases of gastric cancer with ALS after gastrectomy with Billroth-II or Roux-en Y reconstruction. 4,5 T-colostomy in this case caused traction of afferent loop at the level of Treitz ligament, followed with angulation and partial obstruction of afferent loop. ALS may lead impairment of bile and pancreatic drainage while the pressure in afferent loop raised up to 18 cm H2O. 6,7 The abnormal laboratory data such as elevated WBC, amylase and total bilirubin were compatible with pathologic change. 8,9 CT scan is diagnostic tool for ALS, especially to define the obstruction level. 10,11 Managements of acute afferent syndrome can be surgical or nonsurgical. Nonsurgical procedures include external drainage or internal drainage. Internal drainage is done with endoscopic stent in stenotic lesion. 12,13 External drainage is done with percutaneous bowel drainage (PBD) 14,15 or percutaneous transhepatic duodenal drainage (PTDD) 16,17 which depends on the situations of patient.
Lee et al 16 reported that recurrent gastric cancer with ALS had been treated with PTDD with chemotherapy. The PTDD was retained for 11 weeks. The risk of ascending cholangitis, fluid and electrolyte imbalance may be presented no matter the PTDD is patent or not. 18 Nonsurgical therapy might be helpful in poor surgical risk patient or a preparation for more definite surgical intervention like this case. It was faced the dilemma of emergent surgical intervention or temporal PTDD. Patient had high the rate of postoperative complication/mortality ratio in 2 weeks just taking down and closure of the transverse stoma. To avoid the surgical contamination and other complications, PTDD should be considered. PTDD effectively managed postoperative complication and improved of the colorectal cancer patient's condition. It was still doubtful whether the afferent syndrome could be resolved. If PTDD failed, patients would go to an exploratory laparotomy, resection, and anastomosis procedure for the closure and consult with G.S. for reasons of failure including adhesion or tension in the ligament of Treitz.
Recently, hypoxic pelvic perfusion (HPP) could participate interchangeably with surgical and percutaneous approaches in unresectable recurrent rectal cancer (URRC). Tumor drug exposure in the pelvis no statistically difference between the percutaneous approach and surgical approach. 19,20 Minimally invasive techniques usually percutaneous like PTDD with target-therapy could be effective treatment in URRC.
We reported the rare case of after transverse loop colostomy with ALS, which was successfully managed by following management of the ALS by PTDD.

| CONCLUSION
Routine surgery chosen and less experience for the protective stoma is the transverse colon when we noticed the antecolic reconstruction after gastric surgery. In this case report, we found temporal PTDD seems to be effective in the treatment of benign afferent loop symptoms after Tloop colostomy. Ileostomy instead of T-loop colostomy may be suggested for emergent colorectal surgery in patient with previous B-II surgery.